Facelift by Villar

What constitutes a quality face lift and how to identify one?

Surgeons argue endlessly about how best to perform a face lift and ancillary procedures. There is no definitive technique, because we still do not know all the details of the aging process. Val Lambros in California has been photographing patients in 3D and compositing them in a computer. The computer then creates a 3D image and can morph back and forth through the years for each patient. The computer can then average hundreds of patients and we can watch the aging process on a screen. As the database increases, we learn more and more about aging and much of it was unexpected. Before we can fix a problem, we must understand it.

The science and the surgery are evolving. There are common denominators, but each patient is unique and surgery should be customized. It is easier to appreciate poor surgery than to recognize good surgery.

How to identify a face lift By Villar

There are some basic objectives that has stood the test of time. A clean jawline, a smooth neck with restoration of the angle, cheek fullness without distortion, and a clean natural hairline.

Choosing the optimal incisions

The first sign of a poorly executed face lift is loss of hair in the temple area and/or behind the ear.

This resulted from a variation of the traditional incision in which the novice surgeon attempted to hide the posterior incision in the hairline by cutting straight back. The traditional incision up from the ear results in loss of the sideburn hair in patients with lots of excess skin. Cutting straight back violating the natural hairline results in a bald area when the skin is pulled, hairless skin is pulled into previously hair bearing areas.

Hair Loss Sideburn Area

The ideal incision would preserve the natural hairline in front and in back of the ear.

At 4 weeks after lower facelift, there is no distortion of the hairline front or back. The patient can wear her hair up in a pony tale.

Restoring the Jawline and Angle of the Neck

The modern face lift relies on various techniques of tightening and adjustment of the muscles and fascia of the face and neck. Platysma and SMAS plasty or plication are common terms related to the concept of tightening the muscular structures instead of just pulling on the skin which re-stretches rapidly has not stood the test of time.

As we understand the aging process better, we are modifying and improving our techniques. The important thing to remember is that one size does not fit all. Each patient is unique. The initial plan is customized and findings at surgery require the training and ability to think on your feet and adjust as necessary. That is what makes these surgeries so challenging and fun.

This lower face and neck is difficult in that there is no angle to the neck right from the chin. There is a lot of sub-mental fat and significant subcutaneous fat. The jowls extend over the jawline onto the neck, obscuring the jawline. Some would insert a chin implant to obtain an improved neck angle, but this is pleasing to my eye. There is a crease at the base of the neck.

The Plan

The plan is to design an incision that will not distort the hairline in front or behind the ear. We will perform a sharp scissor dissection of the subcutaneous tissue leaving the thickness we want on the skin and the excess will be left on the platysma to be removed with a flat wide cannula with the suction hole face down to avoid irregularities and dents in the skin.. This is left until after the SMAS and platysma have been tightened to give us some leeway to sculpture the jawline. If there is a prominent hyoid, we have a chin implant available, if we need it.

The Execution

The skin was sharply scissor dissected leaving enough subcutaneous fat to preserve the venous plexus to the mid face and across the midline in the neck. The SMAS (Superficial Musculo-Aponeurotic System) was rotated upward and plicated over the zygoma to restore fullness in the cheeks.

Then the platysma muscle was plicated down the midline to restore the angle to the neck. The hyoid was not prominent, so a chin implant was notnecessary. The sub mandibular glands, hidden preoperatively by the jowls, required some tightening of the platysma to better hide them. After the sub-structures were customized to this patient, the skin was pulled back without tension. The fat remaining on the muscle was then sculptured with sharp scissor dissection to define the jawline. The crease at the base of the neck was dissected free of its attachments to the muscle. The skin was pulled tight behind the neck, trimmed and sutured. No staples on my patients. The skin in front of the ear is gently laid, not pulled under tension, marked and cut, then sutured meticulously. No nurse or technician places a single suture because the final closure has to be adjusted meticulously to the patients needs. We consider this a work of art, not assembly line surgery.

At 5 days, sutures are removed in the front of the ear and under chin

At 10 days all sutures are out, good angle, smooth jawline, crease diminished, no dog-ears behind ear. Chin implant was unnecessary. Unrestricted activity allowed at three weeks.